Congenital Pseudarthrosis

The FVFG offers significant advantages in the management of this challenging problem, which usually involves the tibia and in the past often resulted in amputation. It permits resection of all the pathological tissue, which otherwise would be hindered by the reluctance of the surgeon to create a large defect. Moreover, it facilitates reconstruction of the length and alignment of the affected bone. Excellent results have been reported by many authors with union in more than 90% of cases (Fig. 10A.4).

However, potential complications include recurrence of the lesion due to incomplete excision of the pathological tissue and stress fracture of the graft due to difficulty of compliance with restricted weight bearing in children. In addition, valgus deformity of the ankle could develop at the donor site. Fixation of the distal remnant of the fibula to the tibia has been suggested to prevent this complication.

The presence of neurofibromatosis should always be considered in a child presenting with congenital pseudarthrosis and the appropriate evaluation should be undertaken. Congenital pseudarthrosis of the forearm is quite rare, but the limited experience with FVFG management is favorable.

Femoral Head Osteonecrosis

Avascular necrosis of the femoral head is a potentially disabling clinical entity that is currently diagnosed with an increasing incidence most commonly in young adults. In the majority of the cases both hips are affected. The natural history of the disease leads to complete joint degeneration. Arthroplasty is not desirable in the young individuals and a real necessity for joint preserving procedures has led a number of microsurgeons to attempt using a vascularized bone grafts to provide the affected bone with new vasculature and supportive strut graft augmented with spon-giosa. The aim of the procedure is to curette necrotic bone at the subchondral area and substitute it with newly formed callus between the host bone and the transferred graft.

The core of the femoral head is exposed through an extracapsular approach from the lateral aspect of the greater trochanter. A tunnel is created through the femoral neck leading into the osteonecrotic lesion. After curettage of avascular bone the cavity is lined with cancellous autograft and the Free Vascularized fibula graft is inserted in the tunnel. The blood supply is reestablished with anastomosis of the peroneal vessels to the ascending branch of the lateral femoral circumflex artery and one concomitant vein.

Fig. 10A.4. Congenital pseudarthrosis of the tibia in a 2 year old boy, managed with a free vascularized fibula. Adaptive hypertrophy in five months postoperatively allows complete functional recovery without support in five months.

The patient is kept on crutches and partial weight bearing for a period of three to four months until callus formation between the fibular tip, the surrounding spon-giosa and the host bone.

This technique has been popularized by J. R. Urbaniak, MD in the USA who was among the first who started its application 1979, mastered the procedure and performed extensive laboratory and clinical research with vast clinical experience on more than 1500 cases. The long term follow up has demonstrated preservation of the hip joint in 85% of the cases operated prior to articular surface collapse. In patients operated after the establishment of collapse in the articular surface the procedure can delay the need for an arthroplasty up to seven years in 70% of the patients.

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